What is the treatment for nocturnal enuresis (bed wetting) in an 18-year-old woman?

Treatment of Nocturnal Enuresis in an 18-Year-Old Woman

The first-line treatment for nocturnal enuresis in an 18-year-old woman is a combination of behavioral therapy with a bedwetting alarm and desmopressin medication, with treatment tailored based on the underlying pathophysiological mechanism. 1

Initial Assessment

Before initiating treatment, a thorough evaluation is essential to determine if the enuresis is:

• Primary (never been consistently dry) vs. secondary (previously dry for at least 6 months) 2
• Monosymptomatic (bedwetting only) vs. non-monosymptomatic (with daytime symptoms) 1

Key assessment components include:

• Detailed voiding history (frequency, urgency, stream quality, holding maneuvers) 1
• Evaluation for constipation (can contribute to enuresis) 1
• Screening for sleep disorders (obstructive sleep apnea, restless legs syndrome) 1
• Urinalysis to rule out infection, diabetes, or kidney disease 1
• Assessment of fluid intake patterns 1
• Frequency-volume chart documenting wet/dry nights 1

Treatment Algorithm

First-Line Approaches:

1. Behavioral Modifications:

   • Regular daytime voiding schedule (every 2-3 hours) 1
   • Evening fluid restriction (limit to 200ml after dinner) 1
   • Void immediately before sleep 1
   • Treat any constipation with stool softeners if present 1
   • Maintain a calendar of dry/wet nights 1

2. Bedwetting Alarm:

   • Most effective long-term treatment with highest cure rates 1
   • Requires high motivation and family support 1
   • Should be used for at least 2-3 months before judging efficacy 1

3. Desmopressin:

   • Oral tablets (0.2-0.4 mg) taken 1 hour before sleep 1
   • Most effective in patients with nocturnal polyuria 1
   • Approximately 30% full response rate, 40% partial response 1
   • Can be used daily or only before important nights 1
   • Caution: avoid excessive fluid intake to prevent hyponatremia 1

Second-Line Approaches:

1. Combination Therapy:

   • Desmopressin plus alarm for resistant cases 1
   • Desmopressin plus anticholinergics if bladder dysfunction is suspected 3

2. Tricyclic Antidepressants:

   • Imipramine can be considered if other treatments fail 1
   • Effective in 40-60% of cases but high relapse rate 1
   • Caution regarding cardiac side effects 1

Special Considerations for Adult Enuresis

Adult nocturnal enuresis differs from childhood enuresis in several ways:

• More likely to have underlying bladder dysfunction (50% have detrusor instability) 3
• Higher likelihood of requiring maintenance therapy (92% of successfully treated adults) 3
• Greater psychological impact on self-esteem and relationships 2, 4

Monitoring and Follow-up

• Monthly follow-up to sustain motivation 1
• Assess response after 1-2 months of therapy 1
• For successful treatment, continue for at least 2-3 months before attempting to wean 1
• Consider urodynamic studies if treatment fails (may reveal detrusor instability or other abnormalities) 3

Common Pitfalls to Avoid

• Dismissing adult enuresis as purely psychological 4
• Failing to screen for underlying medical conditions 1
• Inadequate duration of treatment before declaring failure 1
• Not addressing comorbid conditions like constipation or sleep disorders 1
• Excessive fluid intake while on desmopressin (risk of hyponatremia) 1

Remember that nocturnal enuresis can significantly impact quality of life and self-esteem, making effective treatment essential even in adults 2, 4. Without treatment, many patients will continue to experience enuresis indefinitely 4.